The Experience of Broken Earth Montreal in Haiti
I initially wrote this article shortly after our mission to Port au Prince and as I was writing, some of the novelty of the trip was beginning to fade into the background of everyday work at the Montreal General Hospital. Still, the mission was a transformative event that permanently affected the participants and at the end, gives an appreciation of how fortunate we are to be able to participate in our health care systems at home (no matter how they could be improved).
Our mission to Haiti ran from January 3 to 10 2017. We are lucky that Port au Prince is a 4.5hr direct flight from Montreal and in the same time zone. There were no transfers and very little time lost in transit. The 13-person team was largely from McGill and was headed by Peter Jarzem (Team Leader) who together with Dr. Ahmed Aoude and Dr. Abdallah Husseini (residents), formed the Orthopedic component of the team. Dr David Bracco and Marco Zaccagnini (resp tech) formed the Anaesthetic contingent while Doctors Ziggy Zeng and Andrew Zachari formed the Gynecologic team. The nursing contingent consisted of Dolores Wright, Byanca Jeune, and Rosemarie Makhoul, and was the motor of the operating experience. Dr Silvana Trifiro treated infections. Mathew and Lucas Jarzem were the clerical staff (filling forms and registering patients). Finally we were joined by Dr Mohammad Mansi in Haiti who provided neurosurgical expertise.
Team Broken Earth (TBE) Montreal works in a Project Medishare hospital. Project Medishare started in 1994 with a group of University of Miami Healthcare workers who set up public health clinics in Haiti. The care model was to combine local and USA-based medical expertise to treat many of Haiti’s most disadvantaged people. This work continued for many years but the efforts were ramped up after the January 2010 Haitian earthquake. Project Medishare created a tent hospital with modern facilities near the Port au Prince Airport complete with operating theater and modern radiology equipment. Most of the injuries were orthopedic, so the donated equipment at the hospital included a large assortment of equipment for orthopedic diagnosis and care. Following the earthquake, Project Medishare began sending teams of surgical specialists to Port au Prince to help at the newly established tent hospital. Most of the local facilities had been destroyed or severely incapacitated by the earthquake and could not accommodate the flood of injuries. The Medishare tent hospital greatly aided the local Haitian efforts. Over 30,000 patients were treated there before the advanced equipment in the hospital was moved to the Bernard Mevs private hospital in June of 2010.
One of the many trauma teams Miami University had an orthopedic Trauma Fellow, Andrew Furey from St John’s Newfoundland. When Andrew returned to St. John’s as a staff surgeon a couple of years later he felt the need to continue his charitable work in Haiti. Andrew set up a Canadian charity he named Team Broken Earth that continued to that work at Bernard Mevs hospital in cooperation with Project Medishare. Dr. Furey is now a board member at Bernard Mevs. His efforts to attract funding for this charitable initiative from sources throughout Canada have been very successful. As the number of teams has multiplied, Andrew and his charity have become well known, well organized and trusted in Haiti and other sites. Each team does its own fund raising but all the money is used for the same purpose: providing care to patients through the Bernard Mevs hospital. Andrew was asked why he chose Haiti and his answer was simple. It is the poorest country in the western hemisphere and one of the poorest in the world. Haiti is in desperate need of advanced care. This was obvious from the moment we left the parking lot in Port au Prince. The average person in Haiti makes about $500 per year and cannot afford basic things as food or clothing much less any type of medical care. All around the airport there are people begging for money and offering to help us move our red equipment bags in exchange for a tip.
Thankfully we cleared customs without a second glance but I admit that while lining up to get through, I was praying that no one looked through the bags and asked me about the 16 crates of spine instrumentation or the multiple kilograms of therapeutic drugs, dressings and gloves that we carried with us. Our equipment weighed close to one metric ton so any searching would be bound to take a long time. We were greeted by two 30 year old UN troop carriers and one equally old box truck for the baggage that took us the few kilometres from the airport to the hospital. The roadways were pandemonium! Fortunately, the driver was accustomed to the complete lack of street signage and stop lights. For 30 minutes we navigated through stop-and-go traffic on streets lined with pedestrians with helmet-free motorcyclists and broken down cars all weaving in and out of the congestion. The effects of the earthquake devastation were obvious with broken buildings and piles of debris mixed with street vendors selling their wares not far from piles of garbage waiting for disposal. We got off the six-lane boulevard and headed down a narrow lane to the gates of the hospital in the heart of Port Au Prince. The hospital was in a mixed industrial neighbourhood next to the Haitian Caterpillar construction equipment outlet and some decrepit concrete buildings. The way into the hospital was blocked by heavily armed guards cradling pump action shotguns in their arms and standing behind fortified steel doors. Eventually we were through the 10-foot high gates and into the hospital. By Haitian standards the hospital was deluxe. The hospital was on a 70m by 70m square campus of low one and two storey buildings that had somehow withstood the earthquake. It had non-potable running cold water and electricity. Because the weather is never cold, the buildings were open to a central courtyard that allowed access to vehicles, patients wheelchairs, and stretchers alike all mixed chaotically. Most of the courtyards were covered to provide shelter from the sun and the rain. We were constantly reminded of where we were by the disrepair of the buildings and equipment. The CT scanner on a trailer in the back had a patient lift that had been broken for three months. There were broken down air conditioner units sitting next to the working replacements. The diesel generators ran 24/7 since the solar panel system’s electric inverters had broken down many months earlier.
We were reminded also by the smiling Haitians. Despite the poverty they were an optimistic and happy group. They worked hard for their sick family members providing nutrition, bedding and personal care for all the patients. This support was critical as the hospital could not afford to pay for food, linens and hospital clothes and relied on family support. At night much of the courtyard turned into an impromptu open air sleeping surface as family member/caretakers bedded down on cardboard mattresses for the night.
Everyone on the mission was totally dedicated to improving the lives of Haitian patients. Why else would you give up a week of your time to work in a place with so many challenges? The excellent Montreal team quickly gelled into a hardworking, efficient unit that performed 27 cases during the five operating days. The variety of cases including drainage of septic hips and knees in children, debridements for flesh eating disease, finger pinnings, tendon repairs, rodding of tibial and femoral fractures, and excision of huge uterine fibroids and massive arm sarcomas. It was a great experience working with this dedicated group of professionals and it was because of their hard work that we were able to do so much during our week. Before leaving Montreal, we carefully documented the available equipment to give us an idea of how we could manage the cases. When we arrived the equipment was all there in massive storage bins lining the main hallway of our newly built modern dormitory.
Since this was our first mission, we were given an orientation to the site and the operating procedures for the week. After seeing emergency patients the evening before surgery, we would select our equipment to have it prepped for use the next day. We had to be very precise about what we needed since only what we picked would be sterilized and ready for use. There could be no last minute changes. We were working at the best trauma centre in Haiti. On the first day, we met our first patient. Your first patient always leaves a lasting impression and this patient highlighted so much of reason we were there. A 24 year old male pedestrian had been hit by a bus and dragged underneath it for many meters. He was unconscious and had a dilated pupil due to severe brain trauma. He was breathing but unresponsive. He had open fractures and many limb and saddle area lacerations that we dealt with over the next few days. Normally in Canada this type of patient would have continuous intracranial pressure monitoring but there was no pressure monitoring available at this centre. We worked hard on this young man stabilizing his fractures, cleaning and repairing his wounds but unfortunately he died a week after we left from complications related to his brain injuries. This man was severely injured by any standard but I wonder if he might have had a better chance at survival if we had the cerebral pressure monitoring equipment and access to modern neurosurgical expertise as we do routinely in Canada.
Our daily routine started with breakfast at 7 and we were in the operating rooms by 8. We stayed there as long as we needed to. We were only 13 people and could not cover all the shifts so we were always finished before midnight and usually before 7 pm. Our group gave as much as they could and willingly accepted the long hours and the basic living conditions. Haiti has many needs but one of the biggest is education. Hospital Bernard Mevs is one of the
Haitian centres known for modern orthopedic surgical care and as such has attracted residents from the two medical schools in the capital city. The residents all speak French and although many speak English we were able to give our lectures in French without a translator. As part of the daily routine, one member of our team gave a lecture most days but the main teaching occurred in the operating rooms where the Haitian residents were shown the techniques we use routinely in Canada.
So, why should residency programs in Canada send medical teams with residents to Haiti or anywhere in the world? Why orthopedic surgeons? Neglected trauma is one of the greatest causes of personal poverty in the third world. About 5 million people die from trauma annually and the number of people with trauma-related permanent disability is between 10 and 50 times higher. Approximately 90% of these injuries occur in developing countries where the impoverished citizens are most severely affected. When a member of a family is injured, the other adults must stop working to offer care; the single injured person makes two people unproductive and unable to provide for their family. If the adult family member does not recover, he goes from bread winner to family burden further impoverishing the whole family. If the patient can recover with modern treatment, both the patient and the family regain their independence.
(WHO bulletin 2009: http://www.who.int/bulletin/volumes/87/4/08-052290/en/)
Should we have taken our residents with us? To be sure, it costs money but is the experience worth the expense? There are many facetsto this question but from the educational perspective you need only ask the residents themselves. They are extremely happy about their experience and believe that their learning accelerated in Haiti. They had practical, first hand, extremely concentrated operative experience six days in a row. They were supervised but were usually the senior resident in each OR. They had experience managing patients from one to 70 years old. They had the responsibility to get to know the patient, the equipment, and the techniques required at a level far in excess of what would have been required in Canada. Realizing they carried this responsibility for every patient created a great sense of ownership and pride in each case that I believe is unmatched in any other teaching environment.
Did using residents negatively affect patient care in Haiti? I do not believe it did. The situation with residents in Haiti is identical to that in Canada. Patient care can thrive as long as the residents are supervised in their activities. The experience in Haiti was actually similar to any teaching hospital environment, although admittedly far more intense.
One of my previous fellows (a participant at the CSS and a fantastic doctor from Palestine about to start a career in Tel Aviv) once told me that Canadians are unaware of how well they live in their country. We have one of the best countries of the world where most levels of society, including the medical system, function well. You only really notice just how well the system works when you step into a situation that is as different as the one in Haiti. For the country receiving the aid, the idea of a medical mission must be tied to permanent change in the local medical institutions. This is called capacity building and Team Broken Earth is slowly building capacity at Bernard Mevs. This has taken many forms over the years. New buildings and equipment, and new teams added to the roster have given TBE greater presence. In May TBE offered an AO trauma basic course in Haiti, the first time this world standard course was held on Haitian soil for Haitian doctors. TBE is not just a tourist charity mission rather it is a lasting effort with the goal of creating a solid foundation for future care. The McGill Team Broken Earth Mission has taken its first step toward setting up a lasting international mission for orthopedic care abroad and we are now making plans for a second mission October 17 to 24, 2017. We eventually want to run two to four missions every year with the goal of creating a permanent McGill teaching presence in Haiti. We brought 16 crates of spine implants with us but did not use them all; future missions will hopefully be able to enlarge the scope of the spine care.
We are indebted to the many orthopedic companies, and institutional and private donors that helped make this trip possible. We are counting on their continuing support. Future resident and hospital staff will have an opportunity to help this charitable cause by joining one of the upcoming missions. We hope that establishing a well-equipped, permanent presence in Haiti will improve patient care and enhance the education of the local staff and volunteers. I believe that our next mission will be even bigger than the mission just passed. There are 13 sites across Canada involved with Team Broken Earth. I encourage anyone who is interested to go to the Team Broken Earth website and get involved.
– Peter Jarzem